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KNEEKNEE OBJECTIVE STABILITYOBJECTIVE STABILITY AND AND
ISOKINETIC THIGH MUSCLE ISOKINETIC THIGH MUSCLE
STRENGTHSTRENGTH AFTER ANTERIOR AFTER ANTERIOR
CRUCIATE LIGAMENTCRUCIATE LIGAMENT (ACL)(ACL)
RECONSTRUCTIONRECONSTRUCTION::RECONSTRUCTIONRECONSTRUCTION::A Randomized SixA Randomized Six--Month FollowMonth Follow--Up StudyUp Study
M. SajovicM. SajovicDepartment of Orthopedics and Sports Department of Orthopedics and Sports
Trauma Surgery, CeljeTrauma Surgery, Celje
General Teaching Hospital Celje, SloveniaGeneral Teaching Hospital Celje, Slovenia
July 28 - 30, San Francisco 2
OMICS - 3rd Int. Conference &
Exhibition on Orthopedics
Anterior cruciate ligament (ACL) rupture is the Anterior cruciate ligament (ACL) rupture is the
most common serious injury of the knee. In the most common serious injury of the knee. In the
general population, an estimated 1 in 3000 general population, an estimated 1 in 3000
individuals sustains an ACL injury per year in individuals sustains an ACL injury per year in
July 28 - 30, San Francisco 3
OMICS - 3rd Int. Conference &
Exhibition on Orthopedics
individuals sustains an ACL injury per year in individuals sustains an ACL injury per year in
the United States, corresponding to an overall the United States, corresponding to an overall
injury rate of approximately 100,000 injuries injury rate of approximately 100,000 injuries
annually.annually.
Several risk factors for tearing the ACL have Several risk factors for tearing the ACL have
been evaluated in literature. The highest been evaluated in literature. The highest
incidence is in individuals 15 to 25 years old incidence is in individuals 15 to 25 years old
who participate in pivoting sports. 70 % of who participate in pivoting sports. 70 % of
ACL injuries occur in noncontact situations. ACL injuries occur in noncontact situations.
July 28 - 30, San Francisco 4
OMICS - 3rd Int. Conference &
Exhibition on Orthopedics
The risk factors for nonThe risk factors for non--contact ACL injuries contact ACL injuries
fall into four distinct categories: fall into four distinct categories:
environmental, anatomic, hormonal, and environmental, anatomic, hormonal, and
biomechanical.biomechanical.
TheThe goalsgoals ofof ACLACL reconstructionsreconstructions
areare toto decreasedecrease symptoms,symptoms, improveimprove
function,function, andand returnreturn patientspatients toto theirtheir
July 28 - 30, San Francisco 5
OMICS - 3rd Int. Conference &
Exhibition on Orthopedics
function,function, andand returnreturn patientspatients toto theirtheir
preinjurypreinjury levellevel ofof activityactivity..
The surgeon has to choose :The surgeon has to choose :
�graft
� fixation
July 28 - 30, San Francisco 6
OMICS - 3rd Int. Conference &
Exhibition on Orthopedics
TheThe mostmost frequentlyfrequently usedused graftsgrafts forfor intraintra--articulararticular
anterioranterior cruciatecruciate ligamentligament (ACL)(ACL) reconstructionreconstruction areare
thethe autologousautologous patellarpatellar tendontendon (PT)(PT) oror doubleddoubled
semitendinosussemitendinosus andand gracilisgracilis tendonstendons (STG)(STG)
autograftsautografts.. ThereThere areare stillstill controversiescontroversies aboutabout graftgraft
July 28 - 30, San Francisco 7
OMICS - 3rd Int. Conference &
Exhibition on Orthopedics
autograftsautografts.. ThereThere areare stillstill controversiescontroversies aboutabout graftgraft
selectionselection forfor primaryprimary ACLACL reconstructionreconstruction..
ACL reconstruction ACL reconstruction
Semitendinosus and gracilis tendon Semitendinosus and gracilis tendon
autograftautograft
(STG)(STG)
July 28 - 30, San Francisco 8
OMICS - 3rd Int. Conference &
Exhibition on Orthopedics
(STG)(STG)
versusversus
Patellar tendon autograft (PT)Patellar tendon autograft (PT)
Operative data Operative data single technique, different transplantsingle technique, different transplant
PT PT transplanttransplant STG STG transplanttransplant
July 28 - 30, San Francisco 9
OMICS - 3rd Int. Conference &
Exhibition on Orthopedics
RESEARCHRESEARCH
ISOKINETIC EVALUATION AND OBJECTIVE ISOKINETIC EVALUATION AND OBJECTIVE
STABILITY OF THE KNEE AFTER ANTERIOR STABILITY OF THE KNEE AFTER ANTERIOR
CRUCIATE LIGAMENT RECONSTRUCTIONCRUCIATE LIGAMENT RECONSTRUCTION
TheThe purposepurpose ofof thisthis studystudy waswas toto analyzeanalyze objectiveobjective
stabilitystability andand isokineticisokinetic strengthstrength ofof kneeknee extensorextensor andand
July 28 - 30, San Francisco 10
OMICS - 3rd Int. Conference &
Exhibition on Orthopedics
stabilitystability andand isokineticisokinetic strengthstrength ofof kneeknee extensorextensor andand
flexorflexor musclesmuscles atat 66 monthsmonths afterafter ACLACL reconstructionreconstruction
usingusing twotwo differentdifferent autograftsautografts (PT(PT versusversus STG)STG) withwith
identicalidentical fixationfixation (interference(interference screws)screws) inin consecutiveconsecutive
patientspatients undergoingundergoing thethe samesame acceleratedaccelerated rehabilitationrehabilitation
programprogram..
From January 2010 to February 2011 57 From January 2010 to February 2011 57
patients were randomly assigned:patients were randomly assigned:
�� Group I (Group I ( 2929 patientspatients ))
STGSTG autograftautograft
July 28 - 30, San Francisco 11
OMICS - 3rd Int. Conference &
Exhibition on Orthopedics
STGSTG autograftautograft
�� Group II (Group II ( 2828 patientspatients ))
PPTT autograftautograft
INCLUSION CRITERIAINCLUSION CRITERIA
�� Time from ACL injury to surgery less than 12 monthsTime from ACL injury to surgery less than 12 months
�� No previous ligamentous injury and surgery of either No previous ligamentous injury and surgery of either kneeknee
July 28 - 30, San Francisco 12
OMICS - 3rd Int. Conference &
Exhibition on Orthopedics
�� No previous meniscal pathology treated with resection No previous meniscal pathology treated with resection or repairor repair
�� No chondral lesions diagnosed by arthroscopy or MR No chondral lesions diagnosed by arthroscopy or MR investigationinvestigation
SURGICAL TECHNIQUE AND SURGICAL TECHNIQUE AND
REHABILITATIONREHABILITATION
�� Apart from the graft harvesting the surgical technique was Apart from the graft harvesting the surgical technique was identicalidentical
�� All procedures were performed by the first author (M.S.)All procedures were performed by the first author (M.S.)
�� Meniscal surgery were performed in 51% of patients in STG Meniscal surgery were performed in 51% of patients in STG
July 28 - 30, San Francisco 13
OMICS - 3rd Int. Conference &
Exhibition on Orthopedics
�� Meniscal surgery were performed in 51% of patients in STG Meniscal surgery were performed in 51% of patients in STG group and in 62% of patients in PT group (group and in 62% of patients in PT group (P P = .408).= .408).
�� All the patients were rehabilitated according to the same All the patients were rehabilitated according to the same accelerated protocol with immediate full weightaccelerated protocol with immediate full weight--bearing and full bearing and full range of motion without use of rehabilitation brace. range of motion without use of rehabilitation brace.
�� The rehabilitation program has been completed in the Unitur The rehabilitation program has been completed in the Unitur Spa and Rehabilitation Center Spa and Rehabilitation Center Zreče Zreče
July 28 - 30, San Francisco 14
OMICS - 3rd Int. Conference &
Exhibition on Orthopedics
METHODSMETHODS
�� AllAll postoperativepostoperative measurementsmeasurements werewere performedperformedinin thethe UniturUnitur SpaSpa andand RehabilitationRehabilitation CenterCenterZrečeZreče byby thethe samesame seniorsenior physicalphysical therapisttherapist
�� IsokineticIsokinetic strengthstrength andand enduranceendurance ofof thetheextensorextensor andand flexorflexor musclemuscle groupsgroups waswas
July 28 - 30, San Francisco 15
OMICS - 3rd Int. Conference &
Exhibition on Orthopedics
extensorextensor andand flexorflexor musclemuscle groupsgroups waswasmeasuredmeasured withwith thethe isokineticisokinetic dynamometerdynamometerEnEn –– KneeKnee (Enraf(Enraf –– Nonius)Nonius)..
�� ObjectiveObjective APAP kneeknee laxitylaxity measurementsmeasurements werewereperformedperformed byby usingusing thethe KTKT--10001000 arthrometerarthrometer(MEDmetric,(MEDmetric, SanSan Diego,Diego, CA)CA)
ISOKINETIC TESTING OF THE ISOKINETIC TESTING OF THE
KNEEKNEE
�� Isokinetic measurements Isokinetic measurements of extensor and flexor of extensor and flexor knee muscles is knee muscles is performed in an open performed in an open kinetic chainkinetic chain
Testing is always Testing is always
July 28 - 30, San Francisco 16
OMICS - 3rd Int. Conference &
Exhibition on Orthopedics
�� Testing is always Testing is always performed on both sides performed on both sides (first healthy then the (first healthy then the injured extremity)injured extremity)
�� Measurements are safe Measurements are safe and have a high and have a high repeatabilityrepeatability
KTKT--22000 arthrometer 000 arthrometer
(MEDmetric, San Diego, CA)(MEDmetric, San Diego, CA)
July 28 - 30, San Francisco 17
OMICS - 3rd Int. Conference &
Exhibition on Orthopedics
METHODSMETHODS
ISOKINETIC AND KNEE LAXITY ISOKINETIC AND KNEE LAXITY
EVALUATIONSEVALUATIONS
EENDURANCE TESTNDURANCE TEST PPOWER TESTOWER TEST KTKT--1000 AP LAXITY1000 AP LAXITY
3 months 3 months
postoperativelypostoperatively
6 months 6 months
postoperativelypostoperatively
6 months 6 months
postoperativelypostoperatively
angular velocity of angular velocity of angular velocity of 60angular velocity of 60°°/s/s KTKT-- 1000 arthrometer 1000 arthrometer
July 28 - 30, San Francisco 18
OMICS - 3rd Int. Conference &
Exhibition on Orthopedics
angular velocity of angular velocity of
180180°°/s/s
angular velocity of 60angular velocity of 60°°/s/s KTKT-- 1000 arthrometer 1000 arthrometer
ROM 20ROM 20°°-- 9090°° ROM 10ROM 10°°-- 9090°° ••134 N134 N
••manual maximum forcemanual maximum force
25 repetitions25 repetitions 6 repetitions6 repetitions average of three average of three
measurementsmeasurements
ISOKINETIC RESULTSISOKINETIC RESULTS
Group STG Group PTGroup PT PP
(STG/PT)(STG/PT)Average
deficit
(%)
SD Average Average
deficit deficit
(%)(%)
SDSD
EnduranEnduran
ce testce test
Extensor Extensor
musclesmuscles
18.8 14.6 21.21.55 1177..66 ..527527
July 28 - 30, San Francisco 19
OMICS - 3rd Int. Conference &
Exhibition on Orthopedics
ce testce test
18018000/s/s
musclesmuscles
Flexor Flexor
musclesmuscles
5.2 13.2 3.3.99 88..66 ..666677
Power Power
testtest
606000/s/s
Extensor Extensor
musclesmuscles
14.0 9.7 2266..77 1100.3.3 .00015.00015
Flexor Flexor
musclesmuscles
3.9 16.8 1.1.44 1100..11 .49.4977
KTKT--1000 measurements at 6 months 1000 measurements at 6 months
postoperativelypostoperatively
Group STGGroup STG Group PTGroup PT PP
(STG/PT)(STG/PT)
Average Average
(mm)(mm)
SDSD Average Average
(mm)(mm)
SDSD
July 28 - 30, San Francisco 20
OMICS - 3rd Int. Conference &
Exhibition on Orthopedics
(STG/PT)(STG/PT)(mm)(mm) (mm)(mm)
134 N134 N 1.1.66 1.5 1.5 11..44 1.6 1.6 . 509. 509
Manual Manual
maximummaximum
1.1.99 1.1.66 11..77 1.1.77 . . 555588
DISCUSSIONDISCUSSION
�� AverageAverage deficitdeficit inin flexorflexor musclemuscle strengthstrength betweenbetween thetheinvolvedinvolved andand thethe uninvolveduninvolved legleg waswas lessless thanthan 66 %% ininbothboth groupsgroups.. ThisThis isis aa veryvery goodgood result,result, particularlyparticularly ininthethe STGSTG group,group, becausebecause previousprevious researchresearch hashas foundfoundthatthat thethe hamstringhamstring tendonstendons harvestharvest significantlysignificantly reducesreducesthethe flexorflexor strengthstrength forfor approximatelyapproximately 11 toto 22 yearsyears afterafter
July 28 - 30, San Francisco 21
OMICS - 3rd Int. Conference &
Exhibition on Orthopedics
thethe flexorflexor strengthstrength forfor approximatelyapproximately 11 toto 22 yearsyears afteraftersurgerysurgery
�� ExcellentExcellent resultsresults resultedresulted fromfrom goodgood surgerysurgery techniquetechniqueofof anan experiencedexperienced surgeonsurgeon asas wellwell asas rehabilitationrehabilitationprogramprogram focusingfocusing onon duedue andand properproper stretchingstretching andandstrengtheningstrengthening ofof flexorflexor musclesmuscles
CONCLUSIONCONCLUSION
�� At 6 months after surgery, we found significantly lower At 6 months after surgery, we found significantly lower
isokinetic quadriceps peak torque in the PT group compared isokinetic quadriceps peak torque in the PT group compared
with the STG group at angular velocity of 60with the STG group at angular velocity of 60°°/s/s
�� WWe did not find significant difference in flexor muscle power e did not find significant difference in flexor muscle power
comparing both groupscomparing both groups
July 28 - 30, San Francisco 22
OMICS - 3rd Int. Conference &
Exhibition on Orthopedics
comparing both groupscomparing both groups
�� We did not find significant differences in knee laxity We did not find significant differences in knee laxity
measurements between the two study groupsmeasurements between the two study groups
�� No significant correlation was found between the knee objective No significant correlation was found between the knee objective
stability and the isokinetic thigh muscle strength.stability and the isokinetic thigh muscle strength.
THANK YOU THANK YOU FOR YOUR FOR YOUR ATTENTIONATTENTION
July 28 - 30, San Francisco 23
OMICS - 3rd Int. Conference &
Exhibition on Orthopedics
ATTENTIONATTENTION